Holding a mirror to the veterinary industry to show the realities you work with every day.
A photographic documentary that relates what working in a busy veterinary practice looks like – the highs, lows, challenges, day-to-day, unusual and extraordinary.
“If only vetting just consisted of treating sick animals. But it didn’t. There were so many other things.”James Herriot, If Only They Could Talk
Part 8: Which direction? How far?
Nothing medical is ever one hundred per cent guaranteed, no matter how much some of us might think so. Arguably, some litigation against doctors arises (where there hasn’t been malpractice) because of the mismatch between expectation and reality. Probably the same goes for some of the cases that are taken to the veterinary board.
Of course, some animal care – vaccinations, de-sexing and dentals – would be considered relatively routine and safe, with clear options and relatively certain outcomes.
But as illnesses become more serious, treating them can be more difficult and the way forward can become much less clear. It seemed at times like trying to navigate through dense fog.
It’s not hard to see why. Humans are complicated, and they bring those complications – emotions, personalities, beliefs, circumstances, and finances – to every consultation. Pets are as complicated, bringing their own emotions, personalities and their biologies. Science adds to it with diagnostic and treatment options, percentage outcomes and risks.
As the severity of an illness increases, it seems to expose and bring into play a lot more of these complexities, particularly as success is harder to predict and the death of a pet looms a little bit larger in the ensuing uncertainty.
In these situations, there might be one right option or multiple right options. Sometimes, any option might only be the first step in a journey through several sets of options. The cost might be one consideration in determining a direction but so might emotion, belief or circumstance.
Many less-than-routine cases came through Brudine while I was there, but Tiah’s case resonated. Tiah held herself with a kind of grace that belied her condition and enamoured me to her.
It started when Tristyn Lowe, Tiah’s owner, discovered a new lump on Tiah’s jaw. She took Tiah to her sister, Dr Arianne Lowe (a vet at Brudine) for examination. Lowe says, “Tiah had lymph nodes up everywhere, and I knew she probably had lymphoma and that it was probably pretty bad.”
Biopsies confirmed the diagnosis and Dr Fiona Starr took over the case. Lowe knew Tiah well through her sister, and Tristyn wanted the change because “it would have been emotionally unfair on Ari [Dr Arianne Lowe] to be making those medical decisions.”
Starr outlines the overarching approach to treating Tiah: “We don’t achieve cure/recovery from lymphoma. Rather, we aim for good quality of life while maximising remission times.”
Lymphoma is a terminal diagnosis, though Starr is clear about one option that isn’t on the table in the first stage of response: “I would never and have never recommended euthanasia when first presented with a lymphoma case; at the most basic level, Prednisolone can still give some good quality of life.”
With quality of life in mind, multi-agent chemotherapy and single-agent chemotherapy options were also suggested, as was being referred to a specialist.
Notably, Tristyn didn’t have financial constraints though, she decided against the multi-agent chemotherapy option, the most expensive of the options and the gold standard.
Tristyn instead chose to begin Tiah’s treatment with single-agent chemotherapy using Doxorubicin. Her decision was mainly driven by the desire to return Tiah to the highest quality of life as quickly as possible, although other considerations came into play, including the shared history between Tiah and Tristyn and treatment likelihoods.
11:55am. Nurse Chelsea Rose sits with Tiah during her 30 minute long course of chemotherapy (Doxorubicin). 23 December 2017
Distance was another factor. Electing for multi-agent chemotherapy would have required a weekly 360km round-trip between Jindabyne, where Tristyn and Tiah lived, and Brudine in Canberra. Tristyn saw this as an impact on Tiah’s quality of life.
Of course, the drive could have been alleviated by using a vet local to Jindabyne, but Tristyn trusted the staff at Brudine.
“Knowing the practitioners and trusting their opinions and experience makes a really big difference,” says Tristyn. That trust in Brudine also meant foregoing the specialist option suggested by Starr.
Besides the personal and practical considerations, Tristyn’s decision-making process was supported by her experience as a general practitioner, which offers an interesting insight from the clinical perspective.
“Multi-agent chemotherapy outcomes weren’t that great for dogs; you might gain six months, you might gain twelve months and you don’t know what kind of side effects they might have. The thing that swayed me to use the Doxorubicin was the fact that, when I talked to Dr Fiona about it, she said that in a lot of dogs, you’ll get a fifty per cent reduction within the first forty-eight hours of the size of the lymph nodes,” says Tristyn.
“My initial thought was to do one dose of the Doxorubicin, to buy some time, and then go to steroids after that.’
Irrespective of option, as Tristyn explains, biology can have a mind of its own and can confound certainty:
“You want to know what the outcomes are going to be but there is no definite answer because each individual, whether it’s a pet or a human, will respond differently to different treatments. You might say that in the majority of dogs, starting on Prednisolone might give four weeks but, in this dog, it might give them another three months, or it might only give them a week. It’s knowing that each of the options aren’t clear and that there’s always going to be a spectrum of outcomes.”
12:12pm Dr Fiona Webb takes Tiah back to her owner after her course of chemotherapy (Doxorubicin). 23 December 2017
In addition to clinical factors, Tristyn was driven by a very personal one: her eleven-year history with Tiah included the death of Tristyn’s partner and it brought deep emotions and memories to the surface.
“Tiah went through a lot of stuff with me, which is probably a big part of what she meant to me. I think that lots of people who underwent the process around her death recognised that it wasn’t just her that I was losing, it was a whole bunch of those memories and experiences,” says Tristyn.
“She went through a period of my life which had a lot of turmoil, and she really provided a lot of stability.”
Starr was sensitive to that emotional need and describes how she approaches this aspect of treatment.
“When dealing with any terminal diagnosis, it is extremely important to be empathetic and receptive to a client’s needs, and this influences a consultation’s progression and treatment. We don’t always hear the background stories behind a case, but the emotions are usually clear. All options are still offered, and time is offered for the client to make an informed decision. However, based on the emotional element, it may place emphasis on extensive workup, versus quick progression to humane euthanasia at the other extreme.”
The decision to use Doxorubicin with a quick return to good quality of life encompassed a large range of considerations to determine a plan of action. It’s a huge amount of information to process and, as is often the case, owners may not have much time to process it.
In Tiah’s case, with an aggressive form of lymphoma, there wasn’t much time at all. Within a couple of days, Tiah developed more lymph nodes, and they grew rapidly to around eight centimetres in diameter.
The Doxorubicin, once administered, had an equal and opposite impact.
“She had a couple of days where she was off her food and she vomited once and that was it,” Tristyn says. “She went from having very little energy and on the third or fourth day, she was out being like, ‘Let’s go walking. Where are my toys? C’mon, let’s play!’”
“Her quality of life in those first five days following treatment was back to how she’d been six months beforehand.”
Starr adds, “The Doxorubicin brought her into remission well. Some dogs don’t show a reduction in node size on single agent Doxorubicin, and hers shrank to normal and stayed normal.”
With Tiah’s response in mind, Tristyn continued with Doxorubicin, rather than steroids as initially planned.
Six weeks and two doses later, though, Tiah, went into liver failure. Tristyn says, “She went off her food, lost all her energy again, became lethargic, was puffing a lot and just uncomfortable.”
It’s unknown whether the liver failure was caused by Doxorubicin or by latent issues with the organ. Irrespective, one option remained.
“That was when the decision to euthanise was made,” says Tristyn. “I got another six weeks of having my dog, and it was ‘her’ until that last week. She was playful, she’d go and get toys and play with them, she was back to her normal self, which was really special.”
“With vet science, there is no single way to do things. I believe in providing options and describing their risks, limitations and costs so that the owner can make an informed decision.”
— Tristyn Lowe (Tiah’s Owner)